Electroconvulsive therapy and other physical treatments

Chapter 31 ELECTROCONVULSIVE THERAPY AND OTHER PHYSICAL TREATMENTS



INTRODUCTION


This chapter covers the use of electroconvulsive therapy (ECT) and other physical treatments for older people with mental health problems. While most ECT is undertaken on an inpatient basis, older persons’ community mental health teams will see people who ultimately need admission to hospital for ECT and may be managing people having outpatient maintenance ECT. Other physical treatments including bright light and physical exercise are most commonly prescribed to outpatients. The chapter finishes with brief mention of some experimental treatments.



ELECTROCONVULSIVE THERAPY


Electroconvulsive therapy (ECT) is the most effective biological treatment currently available for the treatment of severe depression, and can be life-saving. However, its use has been highly stigmatised as a result of its initial use without general anaesthesia and several cinematic depictions in which it was employed in a coercive manner, including in the Academy Award winning film, One Flew Over The Cuckoo’s Nest, starring Jack Nicholson.


ECT involves the administration of a controlled electric current to the brain via scalp electrodes. The electric current induces a short grand mal seizure similar to the grand mal seizures seen in epilepsy. It is normal practice to establish intravenous access and to pre-oxygenate the person prior to induction of anaesthesia. The person is then given a general anaesthetic consisting of an intravenous induction agent (e.g. thiopentone) and a muscle relaxant (e.g. suxamethonium). The psychiatrist then administers the brief electric current. The seizure duration is monitored using an electroencephalographic (EEG) display and printout. The anaesthetist hand ventilates the person for the duration of the anaesthesia, usually about 5 minutes. Experienced nursing personnel then care for the person in a recovery suite after each ECT treatment.


The scalp electrodes used in ECT are small metal discs. For bilateral ECT, the electrodes are placed bitemporally, whereas for unilateral ECT the electrodes are placed over the non-dominant temporal region (usually the right side) and near the vertex of the head. Electrolytic gel is usually applied to the electrodes to improve conduction. Bilateral ECT works a little faster than unilateral ECT, but causes more confusion and amnesia. Right unilateral ECT is usually preferred in older people as it is better tolerated. However, bilateral ECT is still sometimes used in older people, particularly when unilateral ECT has not been effective or when a rapid response is essential.


ECT is indicated principally for severe, treatment-resistant depression. It is often used when people are suicidal or psychotic, or when they are not eating and drinking satisfactorily. ECT is less often used in people with mania, schizoaffective disorder and schizophrenia. The efficacy of ECT in depression has been established through the use of randomised controlled trials (RCTs) comparing real ECT to ‘sham’ ECT. In sham ECT the procedure is exactly the same as for real ECT, but no current is delivered and no seizure induced. The available evidence suggests that ECT works well in older people. Some evidence even suggests that ECT works better in older people than in younger people. Lisanby (2007) gives a clear description of the use of ECT in older people.


In young and middle-aged people, ECT is generally administered three times per week. However, in older people there is a greater risk of post-ECT confusion. To minimise the impact of this, ECT is often administered twice a week or even once a week. People vary considerably in the number of ECT treatments needed to obtain a therapeutic response. Generally, between 6 and 12 treatments are required. Occasionally, as many as 18 treatments may be required.



Consent for electroconvulsive therapy


ECT may be administered on a voluntary basis or on an involuntary basis under the provisions of the relevant Mental Health Act. Fully informed consent is required before voluntary ECT is administered. The person must be informed about the nature of the procedure, including the use of general anaesthesia and the application of an electric current to the head. They must understand that ECT generally involves a course of treatment extending over several weeks, rather than a single treatment. They must be informed about the potential risks of the treatment and about the potential risks of not having the treatment. They must have an opportunity to ask questions and have those questions answered. It is generally best to provide the person with written material about ECT to reinforce information given orally.


The legal requirements for the administration of involuntary ECT vary considerably between jurisdictions. For example, in Queensland, application must be made to the Mental Health Tribunal, except in an emergency situation in which case approval may be granted by a medical superintendent. When involuntary ECT is being considered, it is normal practice to obtain a second opinion from another psychiatrist.



Medical work-up for electroconvulsive therapy


It is important to establish that it is medically safe to administer ECT to the older person. The medical work-up includes a detailed physical examination, screening blood tests and an electrocardiogram (ECG). In some people, respiratory function tests and a chest X-ray are indicated. Although the yield is low, it is common for psychiatrists to order a neuroimaging study (computed tomography (CT) or magnetic resonance imaging (MRI) brain scan) prior to ECT to check for rare causes of raised intracranial pressure. Common relative contraindications to ECT include uncontrolled hypertension and hyperkalaemia (often secondary to chronic renal impairment).

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Aug 6, 2016 | Posted by in GERIATRICS | Comments Off on Electroconvulsive therapy and other physical treatments

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